Anthem defends controversial policy penalizing hospitals who use out-of-network radiologists

Commercial insurer Anthem is defending a controversial new plan to penalize hospitals who use out-of-network radiologists and other physicians. 

Word of the new administrative policy first surfaced in October and is slated to take effect Jan. 1 across 11 states. Anthem plans to punish hospitals by charging a 10% penalty of the allowed amount for claims that involve docs outside of its networks. 

Radiologists and other physicians have roundly criticized the change, labeling the policy as “deeply flawed and operationally unworkable.” The American Hospital Association also joined the chorus on Wednesday with its own sternly worded letter, calling for Anthem parent Elevance Health to rescind the policy. 

However, the Indianapolis-headquartered conglomerate is standing its ground and refusing to honor such requests. Radiologists have charged that the No Surprises Act and its independent dispute resolution process already addresses concerns raised by Elevance. 

“We agree that the federal NSA has fulfilled its intent of protecting patients from unexpected medical bills at the point of care,” Catherine Gaffigan, MD, president of health solutions for Elevance Health, detailed in a Dec. 9 response letter to the American Medical Association and others who wrote to the company in November. “At the same time, our experience shows it has also created incentives for many care providers to remain out-of-network due to extremely high, unsustainable IDR awards—on average around nine times in-network commercial reimbursement rates—resulting from the NSA's IDR arbitration process.” 

Gaffigan also copied multiple imaging groups including the American College of Radiology, Society of Interventional Radiology, and the American Society of Neuroradiology on the letter. She noted that independent dispute resolution awards have “skyrocketed” across the country, with many for nonemergency, planned procedures that “should not ordinarily give rise to surprise bills.”  In its own experience, IDR volumes have surged over 40% in 2025, with providers prevailing in about 85% of cases. Employer-funded health plans have borne nearly 90% of these additional costs, she estimated. 

As one example, she alleged that IDR awards for breast reductions average $90,000 per claim compared to Medicare payment rates of about $1,100. This includes some cases where assistant surgeons supporting the procedure are receiving awards of about $100,000. 

“When awards at these levels become routine for nonemergent cases, the resulting costs are ultimately borne by employers and their employees through higher premiums and out-of-pocket costs, even though individual patients may be protected at the point of services,” she added. “That is the cost pressure this policy is designed to help address.” 

Gaffigan also highlighted previously disclosed exemptions to the policy, including the delivery of emergency services, cases where Anthem has granted prior authorization, and instances when no in-network provider is available. It also exempts rural, critical access and safety net hospitals. States affected include Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio and Wisconsin. 

“We share the AMA’s commitment to patient access and long-term sustainability of the care provider community and welcome the opportunity to continue working together toward those shared goals,” the letter concluded. 

The American College of Radiology shared Elevance’s response in a news update published Thursday, noting it also recently met with the payer in November to discuss radiologists’ concerns. 

“The societies suggested that the best course of action is for the insurer to work with providers on fair contracts that would benefit all parties, including and especially patients,” ACR wrote. “Despite the letters and meeting, the insurer is holding firm on its policy position.”

Richard Heller, MD, MBA, senior VP of public policy for Radiology Partners, also recently discussed the new Anthem policy during a session at RSNA 2025 in Chicago.